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Mental health services have undergone radical transformation in the past 30 years. A community-based care model has largely replaced the acute and long-term care provided in large institutions.

Similar change – from hospital to community-based alternatives – is a long-standing policy objective for physical health care in the United Kingdom. How far the two can be compared has been remarkably under-explored. This paper seeks to correct this by examining the transformation of mental health services in England and the relevance to current policy. Drawing on workshops with those involved in the changes and a review of published literature, the paper explores the context and factors that enabled change to happen in mental health. It includes 10 lessons for service transformation based on these experiences.

Key findings

Transformation of mental health services was not an easy, consistent or linear process. The research and workshops pointed to a combination of factors playing a key role in overcoming resistance and driving transformation.

There was no single driver of change. Key drivers included an increasing optimism about the ability to treat, rather than contain, people with acute and chronic mental health conditions, coupled with a belief that long-term institutional care had detrimental effects.

Social movements and practitioners became increasingly vocal in criticising the care in institutions, exerting pressure for change.

There were innovations in service delivery (eg, needs-based care models, user-led and recovery-orientated community services) underpinned by the principle of case management.

Implications

Moving the location of care without redesigning is not enough – existing services and institutionalised approaches should not simply be replicated in new settings.

High-quality, stable leadership is needed to manage change, handle unexpected demands and results, and ensure vertical integration of expertise, both within the organisation and among voluntary and independent providers.

Greater understanding is needed of professional resistance to change; of GPs’ potential in community-based solutions; of the benefits of co-ordination with other organisations.

Choice of particular care models should be driven by local need, and supported by national mechanisms/policies.

Care pathways should not become overly complex. Services should be developed for each stage of the pathway.

Comments

Ian McPherson

Position

Chair,

Organisation

Improving Health and Wellbeing UK

Comment date

04 February 2014

Having participated in this piece work, its impressive to see how the information and ideas that emerged from the discussions have been translated into a high level analysis of underlying principles with clear practical recommendations.

Dr Daniel Dietch

Position

GP Partner,

Organisation

Lonsdale Medical Centre London NW6 6RR

Comment date

04 February 2014

Good service delivery in the community is possible, but it takes time, expertise and resources. I'm a GP in an inner city practice in London and run a high level diagnostic and management service for patients with bipolar disorder (all types) working closely with Secondary care colleagues, including joint consultations with the patient + GP + Consultant at the surgery. I presented this last week at a Conference at the Institute of Psychiatry at the Maudsley. Over the past few years we have reduced admissions (albeit small numbers) and have been able to really help these patients, many of whom have severe complex illness. But we could do with far better access (= funding and training) to talking therapies.

Dr Daniel Dietch

Position

GP Partner,

Organisation

Lonsdale Medical Centre London NW6 6RR

Comment date

04 February 2014

Good service delivery in the community is possible, but it takes time, expertise and resources. I'm a GP in an inner city practice in London and run a high level diagnostic and management service for patients with bipolar disorder (all types) working closely with Secondary care colleagues, including joint consultations with the patient + GP + Consultant at the surgery. I presented this last week at a Conference at the Institute of Psychiatry at the Maudsley. Over the past few years we have reduced admissions (albeit small numbers) and have been able to really help these patients, many of whom have severe complex illness. But we could do with far better access (= funding and training) to talking therapies.

Cynthia Joyce

Position

Chief Exec,

Organisation

MQ: Transforming Mental Health

Comment date

06 February 2014

Thanks for such an informative report. Great to see that optimism about treatment was a driver for change - hoping to capitalise on that - and indeed, take it to another level in the coming years.
MQ has been formed to stimulate the development of improvements in our diagnosis and treatment tools and practices. We will need that optimism to come from patients and professionals if we are going to make possible.

Ed Macalister-Smith

Position

NHS Leadership Coach,

Comment date

06 February 2014

Mental health services have indeed shown how to move from in-patient, medicalised services to community based multi-disciplinary care. There are certainly lessons to be learned and these should be brought out during whole-system service planning discussions.

And over many years, mental health services have generally done this from a financial position of Cinderella service and flat cash, often having to internally generate the change funds necessary to shift investment and staff.

It hasn't always worked, and it may have taken longer than people originally wanted, so there also some lessons to be learned. But acute and community physical health services should be willing, and be humble enough, to look at this experience on our own doorstep rather than rushing off to the US to look at how to make change happen...

Me Pickup

Position

CEO,

Organisation

Warrington and Halton Hospitals NHS FT

Comment date

10 February 2014

Apols, haven't read the full report just summary but interested to know whether people think the whole transition from ' in institution' to 'out of institution' care is easier to achieve if the same institution delivers the care. I'm conscious that a lot of Mental Health providers remain the provider of both hospital and out of hospital care for their patients, whereas many acute providers are not seen as being a realistic proposition within the community space.

Helen Gilburt

Position

Fellow in Health Policy,

Organisation

The King's Fund

Comment date

11 February 2014

It's great to see the report resonate with so many groups. One area that supported change is the development of multidisciplinary teams which enabled mental health acute providers to deliver a wider range of services in the community. Where they required different skills or resources they worked alongside social care and housing. The same organisation was often involved in providing both the old and new services as they had the expertise in caring for this group of people, but also were able to manage the workforce and financial requirements of transformation.

Jacky Hammond

Position

Director of operations, mental health,

Organisation

Mcch,

Comment date

20 February 2014

Excellent report and a very important subject, this important transformation will only be successful with organisations and sectors working together successfully with a common aim of effecting change safely and with consistency of professional input for an interim period to achieve the best long term outcomes for individuals

Eli Anderson

Position

Master Storyteller & Poet,

Organisation

eAkan

Comment date

05 March 2014

Greetings.
I welcome this report. The impact of working seamlessly with institutional services is the key to a healthy (physically, mentally and spiritually) individual. Pharmaceutical management though important, cannot be the catalyst for holistic change. The individual must be able to use and improve their health using "pathway" services within the community. The more these "community" services are valued by mental health institutions and their allied professionals, i.e. SLT's, CMN, Psychiatrists, integrated therapists, Accupuncturists, etc, the more integrated and embodied the effects for the individual. My current work within both enviroments (institutional and community), demonstrates the efficacy of this integrated approach. We are , again, at the apex of grasping another way, I am committed and will collaborate with others who wish to cocreate services on this basis. The question for others...are you?

Angela Hill

Position

Chair,

Organisation

Suport Association for Mental Health

Comment date

13 March 2014

Have glanced through report but grass roots users who have to use community care are afraid the the required services they need are non existent.
Frequently at meetings I hear that users are returned to the community and told that there mental health care will be sustained, unfortunately it's sadly lacking especially when they need to contact the crisis team an inevitably they return to the acute in patient scenario.
Working mainly within grass roots I hear and observe many various scenarios regarding menta health and often wonder if necessity will force a return to institutional mental health